Friday, 16 June 2017

Addressing the needs of first-time fathers

Roger Watson, Editor-in-Chief

Childbirth is time when attention is, rightly, focused on the woman and the baby. But what about the father and, esepecially, first-time fathers? What are their needs and how can they be addressed? This is  the topic of an article from Singapore by Shorey et al. (2017) titled: 'First-time fathers’ postnatal experiences and support needs: A descriptive qualitative study' and published in JAN.

The study aimed to: 'explore first-time fathers’ postnatal experiences and support needs in the early postpartum period'. Fifteen first time fathers were interviewed  and, hardly unexpectedly, the researchers found: '1) No sense of reality to sense of responsibility, (2) Unprepared and challenged, (3) Support: needs, sources, experience and attitude and (4) Future help for fathers'. For example, one father said: 'One thing that we want to do (as a father) is to get more involved. But, another thing, maybe, from the hospital or from institutes, is telling us what we have to do. So, to be more aware, involve us more so that we will feel more important (laugh)'. The authors concluded: 'This study provides empirical evidence on the experiences and support needs of first-time multiracial fathers in Singapore. The fathers in this study underwent a series of emotional and personal challenges during their transition to fatherhood in the early postnatal period. They shared their support needs and the desire to be considered as an integral part of their family by Singapore healthcare professionals, especially nurses and midwives'.

You can listen to this as a podcast.


Shorey, S., Dennis, C.-L., Bridge, S., Chong, Y. S., Holroyd, E. and He, H.-G. (2017), First-time fathers’ postnatal experiences and support needs: A descriptive qualitative study. J Adv Nurs doi:10.1111/jan.13349

Wednesday, 7 June 2017

Are nurses fit to work?

Roger Watson, Editor-in-Chief

How fit are nurses compared with those they look after - the general population, and what happens to nurses' fitness when they work as nurses? That was the focus of a study from Australia by Perry et al. (2017) which aimed to: 'examine the quality of life of nurses and midwives in New South Wales, Australia and compare values with those of the Australian general population; to determine the influence of workforce, health and work life characteristics on quality of life and its effect on workforce intention to leave'. The outcome of this study is an article published in JAN titled: 'Health, workforce characteristics, quality of life and intention to leave: The ‘Fit for the Future’ survey of Australian nurses and midwives'.

Physical and mental health in over 4,500 nurses was studied over two years in New South Wales and compared with the general public and the characterstics of the nurses related to their fitness was examined. The results showed that nurses were more physically fit than the general public but less fit in terms of mental health. Nurses became less physically fit as they aged but reported better mental health. Nurses with poor mental health were more likely to want to leave their job.

The authors concuded: 'The study provides evidence for nursing/midwifery managers, researchers, decision-makers and policy-makers, and advocates for the development and implementation of targeted interventions for the nursing and midwifery workforce. Findings indicate potential benefit in terms of staff quality of life and workforce retention, for interventions focused not only on mental health, well-being, coping and resilience particularly but also on better sleep, pain reduction, smoking cessation and general health screening/health promotion.

You can listen to this as a podcast


Perry, L., Xu, X., Duffield, C., Gallagher, R., Nicholls, R. and Sibbritt, D. (2017), Health, workforce characteristics, quality of life and intention to leave: The ‘Fit for the Future’ survey of Australian nurses and midwives. J Adv Nurs. doi:10.1111/jan.13347

Tuesday, 6 June 2017

Can a nurse who smokes promote health?

Roger Watson, Editor-in-Chief

Does it matter if a nurse smokes? Will they be effective at health promotion? This was the subject of an article from Spain which was based on a study aiming to: 'explore the views of current and ex-smoker nurses on their role in supporting patients to stop smoking.' The article by Mijika et al (2017) was titled: 'Health professionals’ personal behaviours hindering health promotion: A study of nurses who smoke'.

The study used interviews with nurses who had or who still smoked in one hospital in Spain. The views of the nurses varied; one nurse who thought it made no difference said: 'I think that in terms of patients it (being a nurse who smokes) doesn’t have an impact (on the care provided to the patient), I mean . . . the patient knows, when you are at work you are a nurse...'. But another disagreed, saying: 'I think it does have an impact. I think it does. [. . .] For example, if a patient is trying to quit and has a lung cancer and a smoker nurse who smells of tobacco approaches him advocating for something that she’s doing wrong. . ., that has to provoke some kind of reaction in the patient.' Even in the face of patients ill from a smoking related disease, nurses were able to justify smoking: 'I have experienced situations like when you are taking care of a patient who is very ill, grasping for breath, with a lung cancer, the family very uptight, with...very bad...and I have got out and said “I’m going to smoke.” I mean situations that overwhelm you, that you can’t control with medication, that you can’t control...that affects your human nature, you know?'

The authors concluded: 'Nurses with an unhealthy behaviour such as smoking experience
internal processes that might have a negative impact when engaging in health promotion practice. Smoking nurses may be inhibited as health promoters without noticing it, and they may need help to
address the conflict that they experience between their professional responsibility and their smoking behaviour. If health promotion practices are to be enhanced, interventions that help these health professionals are necessary.'

You can listen to this as a podcast


Mujika, A., Arantzamendi, M., Lopez-Dicastillo, O. and Forbes, A. (2017), Health professionals’ personal behaviours hindering health promotion: A study of nurses who smoke. J Adv Nurs.  doi:10.1111/jan.13343

Monday, 5 June 2017

Response to commentary on Blake, Stanulewicz & McGill (2017) Predictors of physical activity and barriers to exercise in nursing and medical students

Response to commentary on Blake, Stanulewicz & McGill (2017) Predictors of physical activity and barriers to exercise in nursing and medical students. Journal of Advanced Nursing, 73(4), 917-929

Holly Blake
Natalia Stanulewicz
Francesca McGill

On the May 10th 2017, JAN interactive published a commentary on Blake, Stanulewicz and McGill (2017) by Chappel et al. (2017). The authors of the commentary raised two main concerns regarding the study:(1) a possible misinterpretation of physical activity (PA) as solely “formal exercise” by the participants, and (2) a questionable extrapolation of the proposal for the need for PA interventions from student to staff nurse populations.

Regarding the first concern, the IPAQ-SF has been established as a reliable measure (e.g., Craig et al., 2003), that has been employed extensively across populations, cultural groups and demographics, and is extensively utilised worldwide. It was the preferred measure for use in this study due to its short format and ease of use, and has been described as ‘the most appropriate outcome measure for clinical and research use, as it has excellent reliability and moderate correlation with accelerometry’ (Silsbury et al, 2015).

We cannot report on exactly how participants interpreted the individual IPAQ-SF items in this online survey, although the measure includes items relating to walking, and vigorous or moderate intensity activities, and examples of activities were provided. Importantly, our participants were healthcare students, who receive education and training around health behaviours as part of their studies. At the institution where the data were collected, this includes both the distinction between types and levels of PA, and the relevance of work-related PA (including incidental activities) and their contribution to overall daily activity. Therefore, recognising there will be individual variation in the retention of learning, the overall potential for misinterpretation of PA and what it entails is likely to be low, or certainly lower in this sample than for other populations. For nurses, health promotion is a core aspect of their future professional role and as such is emphasised early in the first year of training.

We accept that PA may be either under, or over-reported using self-report measures, and that objective data is required to accurately measure PA levels. We do not dispute the potential for under-reporting of PA, although a systematic review of the validity of the IPAQ-SF including 23 studies, found that in almost all of the included studies, PA was actually overestimated using the IPAQ-SF by 36-173% (Lee et al, 2011).

Chappel and colleagues were concerned about extrapolating from student nurse to nurse populations, given the likelihood of higher PA in nurses within clinical settings. However, we remain convinced that our recommendations, based on our student sample and taken in context alongside the published literature, remain highly relevant to nurses as well as students of nursing.

First, workplace PA interventions can generate benefits in a range of occupational groups (see review by Anderson et al, 2009) including occupations incurring highly physical demands, such as home care workers (Pohjonen & Ranta, 2001). Physically demanding work does not necessarily have positive effects on physical fitness and so worksite PA intervention may offer additional benefits beyond work-related activities Further, we make no claim in our article that nurses and healthcare students are one and the same, although it is of clear relevance that all of the nursing students who completed our survey were registered on courses involving integrated clinical placements, and were regularly working alongside registered nurses in diverse clinical areas; therefore it follows that they may be exposed to similar work-related physical activities, and they were asked to report their activities with relation to clinical placements as well as university time.

Second, if high levels of work-related PA are observed in nurses (note: we do not know how this compares with students PA whilst on shifts), or if registered nurses self-report higher levels of PA than student nurses, we feel it would be unwise to focus only on the differences between the two populations in debating where to target PA intervention. The published evidence suggests that barriers to exercise reported by both groups can be similar, and that many nurses and students [a] do not meet government recommendations for daily PA, [b] are overweight or obese, and [c] report that their own health habits can impede their willingness to promote PA to patients. This sits clearly in line with the national call for health improvement of the health and medical force made in the 2010 Prime Minister’s Commission on the Future of Nursing and Midwifery in England, and the current government investment in health and well-being through the NHS Five Year Forward Plan.

With efforts to increase retention of nursing graduates, there is an increasing drive to instil healthy lifestyle behaviours in student nurses to ensure a healthy public health workforce for the future. This may help to establish patterns of healthy behaviours early on that will continue into the nursing career, and be promoted to patients and their families. Patterns of health behaviours that are established early on are likely to continue beyond registration and through the nursing career. Orr et al (2014) propose that PA positively correlates with motivation, well-being, coping and positive attitude, and that these attributes in turn impact on employability, retention and absence; they advocate that poor health and well-being of nurses may present risks around fitness to practice and may even breach the Nursing and Midwifery Council (NMC) Code of Conduct. These are all relevant factors for students and nurses, and for the transition between the two roles; and so it would be challenging to claim that these populations were unrelated.

Thus, we propose that health behaviours should be advocated and supported from student through to registered nurse rather than focusing solely on [i] either group, or [ii] the potential differences in PA between groups becoming determinants of whether it is timely to offer services, to which group, and to the exclusion of the other. Because of this we strongly disagree that it is premature to advocate PA intervention for nurses in the NHS workplace informed by findings from our sample, which sits alongside a wealth of published research evidence and national government-funded workplace intervention programmes.

Both nurses and nursing students consistently report low levels of PA, high levels of overweight and obesity, and barriers to healthy lifestyles influenced by common variables such as time pressure and shift work. We now need to move forwards in supporting healthcare professionals (of the current and next generation) to make healthy lifestyle choices. In workplace health practice, service commissioners do not necessarily distinguish between nurses and trainees who are not yet registered when it comes to promoting health – they all contribute to NHS healthcare through the profession of nursing, and can all access the same workplace physical activity interventions (see Nottingham University Hospitals NHS Trust as an exemplar of NHS well-being: Blake et al, 2013) and a ‘flagship’ trust in the UK Department of Health Five Year Forward Plan.

The ultimate goal of promoting PA to nurses or student nurses is broadly the same: to protect the physical and mental health of individuals, to reduce unnecessary burden to the NHS, and to support high quality patient care.

Dr Holly Blake
School of Health Sciences
University of Nottingham, UK

Natalia Stanulewicz
Department of Psychology
Durham University, UK

Francesca McGill, RN
Alder Hey Children’s Hospital
Liverpool, UK


Anderson LM, Quinn TA, Glanz K, Ramirez G, Kahwati LC, Johnson DB, Buchanan LR. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: A systematic review. Am J of Prev Med. 2009 Oct;37(4):340-57. doi: 10.1016/j.amepre.2009.07.003.
Blake H, Zhou D, Batt ME. Five-year workplace wellness intervention in the NHS. Perspect Public Health. 2013 Sep;133(5):262-71. doi: 10.1177/1757913913489611.
Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, Pratt M, Ekelund U, Yngve A, Sallis JF, Oja P. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003 Aug;35(8):1381-95. doi: 10.1249/01.MSS.0000078924.61453.FB.
Lee PH, Macfarlane DJ, Lam TH, Stewart SM. Validity of the International PA Questionnaire Short Form (IPAQ-SF): a systematic review. Int J Behav Nutr Phys Act. 2011 Oct 21;8:115. doi: 10.1186/1479-5868-8-115.
Orr J, McGrouther S, McCaig M. Physical fitness in pre-registration nursing students. Nurse Educ Pract. 2014 Mar;14(2):99-101. doi: 10.1016/j.nepr.2013.10.002.

Pohjonen T, Ranta R. Effects of worksite physical exercise intervention on physical fitness, perceived health status, and work ability among home care workers: five-year follow-up. Prev Med. 2001 Jun;32(6):465-75.

Silsbury Z, Goldsmith R, Rushton A. Systematic review of the measurement properties of self-report PA questionnaires in healthy adult populations. BMJ Open 2015;5:e008430. doi:10.1136/bmjopen-2015- 00843

Wednesday, 31 May 2017

Nurses' Health Virtual Issue

The American Nurses Association has declared 2017 the Year of the Healthy Nurse. In recognition of this, JAN has put together a special Virtual Issue, comprised of previously published papers addressing key areas of nurses’ health, including the connection between health, workplace participation and strategies nurses use to self-manage their health and well-being.

All the JAN articles in the Virtual Issue will be free to access until 12 November 2017:

Breastfeeding in the face of domestic violence

Roger Watson, Editor-in-Chief

Can mothers continue to breastfeed if they are experiencing domestic violence? If so, what effects does it have on them? This was the topic of  an article from from Sweden by Finnbogadóttir and Thies-Lagergren (2017) titled: 'Breastfeeding in the context of domestic violence – a cross sectional study' and published in JAN aimed to: 'determine the differences in breastfeeding among women who did and did not experience domestic violence during pregnancy and postpartum in a Swedish context. In addition, to identify possible differences regarding breastfeeding between groups with or without a history of violence. Further, determine the relationship between exclusive breastfeeding and symptoms of depression'. Over 700 women resopnded to a questionnaire.

In fact, the majority of women experiencing domestic violence continued to breastfeed and this was no different from women not experiencing it. However, women who were depressed breastfed significantly less. This, of course, does not mean that women exeperiencing domestic violence did not experience difficulties with breastfeeding - but this was not part of the present study. It is still important to screen for domestic violence and also for depression. In conclusion the authors said: 'Not only is it desirable to recognize women who are exposed to violence but also crucial to identify and screen for depression in early pregnancy to give suitable treatment and support to those with symptoms of depression as the health of newborns depends on their mother’s mental well-being.

Yiou can listen to this as a podcast


Finnbogadóttir, H. and Thies-Lagergren, L. (2017), Breastfeeding in the context of domestic violence – a cross sectional study. J Adv NursDO10.1111/jan.13339

Tuesday, 30 May 2017

Using social media to recruit nurses

Roger Watson, Editor-in-Chief

Nursing organisations and hospitals were slow to adopt social media and some hospitals even had Twitter accounts and Facebook pages while prohibiting their employees from making any mention of their work in their own social media pages. However, while employees are expected to behave responsibly, there is much greater recognition of the use of social media in nursing and healthcare. But can hospitals use social media to make themselves more attractive to potential employees? 

An article from Belgium by Carpentier et al (2017) titled: 'Recruiting nurses through social media: Effects on employer brand and attractiveness' and published in JAN addresses this issue. The study on which the article is based aimed to: 'investigate whether and how nurses’ exposure to a hospital’s profile on social media affects their perceptions of the hospital’s brand and attractiveness as an employer'. Specifically, the study looked at one hospital's use of Facebook and LinkedIn to promote themselves and sent out questionnaires to nursing students and qualified nurses to look at how attractive the hospital was as an employer.

The results show that: '(n)urses’ exposure to the hospital’s Facebook or LinkedIn page had a significant effect on a majority of the employer brand dimensions' which included aspects such as image and attractiveness. Also, 'nurses who visited the Facebook page felt more attracted to working at the hospital. Most of these effects were mediated by social presence.'  In conclusion, the authors say: 'This study indicates that hospitals’ investments in social media can be justifiable because they can have a positive effect on potential applicants’ organizational attractiveness and employer brand perceptions.'

You can listen to this as a podcast


Carpentier, M., Van Hoye, G., Stockman, S., Schollaert, E., Van Theemsche, B. and Jacobs, G. (), Recruiting nurses through social media: Effects on employer brand and attractiveness. J Adv Nurs. Accepted Author Manuscript. doi:10.1111/jan.13336

Wednesday, 24 May 2017

Orthopaedic Nurse Practitioners shorten hospital stays and save money

Roger Watson, Editor-in-Chief

The case for advanced nursing roles has been well supported by evidence, much of it published in JAN, and a new study from Australia demonstrates the value of Nurse Practitioners in orthopaedics. The study by Coventry et al. (2017) aimed to: 'compare acute hospital length of stay and cost-savings for patients with hip fracture before and after commencement of the Orthopaedic Nurse Practitioner and identify variables that increase length of stay in hospital' and the article published in JAN is titled: 'Impact of the Orthopaedic Nurse Practitioner role on acute hospital length of stay and cost-savings for patients with hip fracture: A retrospective cohort study'.

The length of patient stay was related to co-morbidities such as dementia and cardiovascular disease but lengths of stay (LOS) were reduced using Orthopaedic Nurse Practitioners (ONP) and '(the) cost-savings to the hospital over one year was $354,483 and the net annual cost-savings per patient was $1,178.' The authors concluded: 'This study has shown that implementation of the role of the ONP significantly decreased acute hospital LOS without increasing mortality or complication rates. Further research is required into interventions that optimize time to surgery, manage anaemia and co-morbid conditions, reduce complications and lead to improved patient outcomes.'

You can listen to this as a podcast


Coventry, L. L., Pickles, S., Sin, M., Towell, A., Giles, M., Murray, K. and Twigg, D. (2017), Impact of the Orthopaedic Nurse Practitioner Role on Acute Hospital Length of Stay and Cost-savings for Patients with Hip Fracture: A Retrospective Cohort Study. J Adv Nurs. DOI: 10.1111/jan.13330

Tuesday, 16 May 2017

Women living with polycystic ovary syndrome

Roger Watson, Editor-in-Chief

According to the UK website NHS Choices polycystic ovary syndrome (PCOS) three main features are:

  • irregular periods – which means your ovaries don't regularly release eggs (ovulation)
  • excess androgen – high levels of "male hormones" in your body, which may cause physical signs such as excess facial or body hair
  • polycystic ovaries – your ovaries become enlarged and contain many fluid-filled sacs (follicles) which surround the eggs (it's important to note that, despite the name, if you have PCOS you don't actually have cysts).
The aim of this study from the UK by Tomlinson et al (2017) titled: 'The diagnosis and lived experience of polycystic ovary syndrome: A qualitative studyand publised in JAN was to: 'explore the impact of the diagnosis of polycystic ovary syndrome on health/ill health identity, how women experience this diagnosis and their health beliefs'. Thirty-two women were interviewed and a range of concerns were identified including: 'general lack of empathy by the medical profession'; 'difficulty in accessing specialist referral'; 'lack of information from professionals' amongst other things. 

The authors concluded: 'Women face a great deal of uncertainty as the diagnosis of PCOS is not straightforward and this leads to a view that the medical profession has little regard for the emotional and social consequences of their condition. However, from a medical perspective, the doctors also face uncertainty as there are many conditions that can mimic PCOS. These findings suggest that the experience of women with PCOS would be improved if their principal concerns were better addressed.'

You can listen to this as a podcast


Tomlinson JPinkney JAdams L, et al. The diagnosis and lived experience of polycystic ovary syndrome: A qualitative studyJ Adv Nurs. 2017;00:19

Wednesday, 10 May 2017

Putting the ‘Physical’ Back into Nursing: Recognising Nursing as a Physically Demanding Occupation

Commentary on: Blake, H., Stanulewicz, N. & McGill, F. (2017) Predictors of physical activity and barriers to exercise in nursing and medical students. Journal of Advanced Nursing, 73(4), 917-929

Stephanie E. Chappel
Julie Considine
Brad Aisbett
Nicola D. Ridgers

In the April issue of JAN, Blake et al. (2017) investigated predictors of physical activity and barriers to exercise in nursing and medical students. Of specific interest are the findings related to nursing that showed close to 50% of nursing students were not meeting the national physical activity guidelines of 150 minutes of moderate-intensity physical activity a week (Department of Health 2014). Further, the most common barriers to nursing students’ engaging in physical activity were that physical activity was tiring, hard work, time-consuming, caused fatigue, and did not suit inconvenient work schedules (Blake et al. 2017). Blake and colleagues (2017) suggested that physical activity should be promoted to nursing students, and interventions should be tailored more broadly to accommodate the barriers of shift work.

However, these recommendations raise several questions. First, it is possible that physical activity, which is any movement requiring energy (Caspersen et al. 1985), was misinterpreted by the participants as exercise, which is planned physical activity (Caspersen et al. 1985), leading to an underestimation of actual activity levels. Second, physical activity occurs in a range of domains, including household duties, active transport, leisure-time and occupational activity (Hagströmer et al. 2006). The short version of the International Physical Activity Questionnaire (IPAQ) used in this work only captures a summary of all physical activity across a week and, does not separate physical activity into different domains (Hagströmer et al. 2006). The IPAQ also asks individuals to report the amount of walking completed in the last week, which can be misinterpreted as purposeful walking for exercise. Incidental walking that may occur at work (e.g., to and from a patients room; Hagströmer et al. 2006) may be under-reported. Finally, as with any subjective measure, there is potential for recall bias that can lead to an under- or over-estimation of actual physical activity levels; a limitation acknowledged by Blake et al. (2017). To avoid issues related to subjective reporting of physical activity, Blake et al. (2017) suggests future work should use objective monitoring, such as accelerometers, to more accurately capture physical activity. A particular advantage of using accelerometers would be the ability to quantify physical activity levels at work, given collected data are date- and time-stamped.

We recognise that this study was focused on students, although Blake et al. (2017) recommend that the healthcare workforce needs strategies to increase physical activity for shift workers. This conclusion raises several questions about whether nursing students are representative of a nursing workforce, and, whether data from nursing students were collected during clinical placement. Interestingly, in addition to nursing students, Registered Nurses (RNs) have also been identified as not meeting the national physical activity guidelines through their leisure-time physical activity (Naidoo and Coopoo 2007, Ahmad et al. 2015, Jung and Lee 2015), leading to a national focus on promoting nurses’ engagement in physical activity (National Insititue for Health and Care Excellence 2015). However, many of the claims that nurses do not meet physical activity guidelines and calls for increased physical activity among nurses are based on leisure-time activity alone. Given that a considerable proportion of waking hours are spent at work (Kikuchi et al. 2015), it is potentially misleading to conclude that strategies are required when occupational activity is not captured.

Although a lack of time and tiredness are consistently reported as the barriers to physical activity by both nursing students and RNs (Blake et al. 2017, Chin et al. 2016, Jung and Lee 2015), there is variability in the drivers of these barriers for physical activity. Nursing students are required to balance study, work and clinical placements that may or may not involve shift work (Blake et al. 2017). For RNs, lack of time is most likely the result of shift work as they spend majority of their waking hours at work (Kikuchi et al. 2015). Shift work also causes tiredness as sleep patterns are disrupted, yet this is further compounded by the physical demands of nursing work (Chin et al. 2016). Nursing involves several physically demanding tasks such as cardiopulmonary resuscitation, transferring patients, and pushing beds and wheelchairs. Studies have shown that in one shift nurses can lift up to 1800 kilograms (Babiolakis et al. 2015), maintain a high heart rate (51-64% maximal heart rate; Chen et al. 2011), and walk over 15,000 steps (Wakui 2000) or up to 8 kilometres (Chen et al. 2011). These physiological measures suggest that nurses are engaging in high amounts of physical activity through their daily duties and, are potentially meeting physical activity guidelines through their occupational physical activity. It is therefore too early to conclude that workplace physical activity interventions are required to increase nurses’ leisure time activity when little is known about nurses’ physical activity during a shift and the interaction between different domains of physical activity is poorly understood.

Nursing has been described as a physically demanding occupation. Yet despite the predominance of nurses in healthcare delivery, the ‘physical’ aspect of their work is poorly understood. A detailed understanding of nurses’ occupational physical activity using robust, valid measures is lacking. In order to ensure that nurses can provide the best care to their patients, there is an urgent need to understand the physical demands of nursing work.

Ms. Stephanie E. Chappel, BExSc (Hons)
PhD Candidate
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @Steph_Chappel

Professor Julie Considine, PhD
Professor of Nursing
School of Nursing and Midwifery and Centre for Quality and Patient Safety Research
Deakin University, Geelong, Victoria
and Centre for Quality and Patient Safety Research – Eastern Health Partnership
Box Hill, Victoria
Twitter: @julie_considine

Associate Professor Brad Aisbett, PhD
Associate Head of School (Teaching & Learning, Exercise and Sports Science)
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @BradAisbett

Dr Nicola D. Ridgers, PhD
Senior Research Fellow
Institute for Physical Activity and Nutrition (IPAN)
Deakin University, Geelong, Victoria
Twitter: @NickyRidgers


Ahmad, W., Taggart, F., Shafique, M.S., Muzafar, Y., Abidi, S., Ghani, N., Malik, Z., Zahid, T., Waqas, A. & Ghaffar, N. (2015) Diet, exercise and mental-wellbeing of healthcare professionals (doctors, dentists and nurses) in Pakistan. PeerJ, 3, e1250.

Babiolakis, C.S., Kuk, J.L. & Drake, J.D.M. (2015) Differences in lumbopelvic control and occupational behaviours in female nurses with and without a recent history of low back pain due to back injury. Ergonomics, 58(2), 235-245.

Blake, H., Stanulewicz, N. & McGill, F. (2017) Predictors of physical activity and barriers to exercise in nursing and medical students. Journal of Advanced Nursing, 73(4), 917-929.

Caspersen, C.J., Powell, K.E. & Christenson, G.M. (1985) Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 100(2), 126.

Chen, J., Davis, L.S., Davis, K.G., Pan, W. & Daraiseh, N.M. (2011) Physiological and behavioural response patterns at work among hospital nurses. Journal of Nursing Management, 19(1), 57-68.

Chin, D.L., Nam, S. & Lee, S.J. (2016) Occupational factors associated with obesity and leisure-time physical activity among nurses: A cross sectional study. International Journal of Nursing Studies, 57, 60-69.

Department of Health (2014) Australia's Physical Activity and Sedentary Behaviour Guidelines. Vol. 2016. Commonwealth of Australia, Canberra.

Hagströmer, M., Oja, P. & Sjöström, M. (2006) The International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity. Public Health Nutrition 9(06), 755-762.

Jung, H.-S. & Lee, B. (2015) Contributors to shift work tolerance in South Korean nurses working rotating shift. Appl Nurs Res, 28(2), 150-155.

Kikuchi, H., Inoue, S., Odagiri, Y., Inoue, M., Sawada, N. & Tsugane, S. (2015) Occupational sitting time and risk of all-cause mortality among Japanese workers. Scand J Work Env Hea, 41(6), 519-528.

Naidoo, R. & Coopoo, Y. (2007) The health and fitness profiles of nurses in KwaZulu-Natal. Curationis, 30(2), 66-73.

National Insititue for Health and Care Excellence (2015) Physical activity: for NHS staff, patients and carers.

Tuesday, 9 May 2017

Balancing Quality, Cost and the Nursing Workforce

Balancing Quality, Cost and the Nursing Workforce

Claire Su-Yeon Park, MSN, RN
CEO, Center for Econometric Optimization in the Nursing Workforce, Seoul

How can we achieve value-based nursing care resulting from improved quality yet reduced cost? We long for the best point of leverage balancing quality and cost; however, most studies seem to still present fragmented “snap shots” of the phenomenon of interest. We should be mindful of this because an unclear picture may lead to muddled policy-making. In this regard, I proposed a theory entitled “Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory” which explains “the inter-relationship in the continuum of changes between quality of care and cost, in particular, as they relate to nurse staffing.” The study “Optimizing staffing, quality and cost in home healthcare nursing: Theory synthesis” (Park 2017) is published in JAN.

I took note of inconsistent and non-conclusive evidence on both quality and cost in home healthcare, gaining insight into the limited theoretical basis on the dynamics between quality and cost that such evidence must be built upon.

To address this discrepancy, we created “Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory” through the theory synthesis process, which helps determine a practical and applicable optimum level of nursing staffing where nurses, patients and healthcare organizations (or stakeholders) can all be satisfied. The specific approach pinpoints “the theory-driven Optimum Nurse Staffing Zone as well as the Optimized Nurse Staffing (Sweet Spot), which can be navigated by Mathematical Programming (Optimization) based on the Duality Theorem in Mathematical Economics (Diewert 1982, p. 556)” (Park 2017). The “Optimized Nurse Staffing (Sweet Spot)” signifies a single best point of leverage “to achieve the maximum quality of care for patients while simultaneously delivering nurse staffing in the most cost-effective way” (Park 2017).

Non-linear optimization illustration produced by MATLAB

My theory could significantly impact nursing workforce policy-making to ensure optimal patient care relative to cost. “Not only does it address a timely issue – i.e., the balance between quality and cost – in the healthcare delivery system, but it is also applicable, durable and valuable due to the fact that Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory can be used to determine the sweet spot among quality, nurse staffing and cost in any healthcare/research setting” (Park 2017). Innovation in the healthcare delivery system as well as advancing nursing practice in real-world situations would be ultimately achievable.

Claire Su-Yeon Park, MSN, RN
CEO, Center for Econometric Optimization in the Nursing Workforce
Seoul, Republic of Korea


DIEWERT W.E. (1982) Duality approaches to microeconomic theory. In Handbook of Mathematical Economics: Volume II (Arrow K.J. & Intiriligator M.D., eds.), North-Holland Publishing Company, Amsterdam, Netherlands, pp. 535-599.

PARK C.S. (2017) Optimizing staffing, quality and cost in home healthcare nursing: Theory synthesis. Journal of Advanced Nursing. doi: 10.1111/jan.13284.

Note: This article is published under an exclusive license agreement with John Wiley & Sons, Limited; Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory: Copyright ⓒ 2016 Park, Claire Su-Yeon. All Rights Reserved. The copyright has been registered in Korea [C-2016-031091] and is pending in the U.S.A. [1-4218094011] with an effective copyright date of 02 Dec 2016; patent-pending in Korea (Park’s User-friendly Cloud-based Intersectional Optimized Nurse Staffing (Sweet Spot) Decision-making Support System [10-2017-0052130] with an effective patent-pending date of 24 Apr 2017); the Patent Cooperation Treaty (PCT) patent claiming priority of the Korean patent application pending [in progress]. Use of the contents, illustrations, and even ideas in Park’s Optimized Nurse Staffing (Sweet Spot) Estimation Theory, even in part, requires written permission from the copyright/patent holder.

Tuesday, 2 May 2017

Disaster leads to disaster

Roger Watson, Editor-in-Chief

Disaster leads to disaster - at least, that's the case for adolescent girls after a natural disaster, according to a study from the USA by Sloan et al (2017 and published in JAN. The article is titled: 'Experiences of violence and abuse among internally displaced adolescent girls following a natural disaster' and was based on a study following the 2010 earthquake in Haiti.

Can you imagine losing your home and possibly your whole family as an adolesecent girl in the wake of a devastating earthquake and ending up homeless, hungry and alone? Could anything be worse? Well, in the case of adolescent girls in Haiti, it could and it did. The study set out to: 'describe the physical, psychological and sexual violence among internally displaced adolescent girls following the 2010 Haiti earthquake.' Computer assisted self-interviews were used to collect information between 2011-2013. The majority of the 78 girls who responded reported some kind of abuse - including sexual - at the hands, often, of boyfriends or other family members. It should be noted that such abuse was reported prior to the earthquake and, due to the low response rate to questions about abuse prior to the earthqaake, it was not entirely clear if there had been an increase.

In conclusion, the authors say: 'The findings from this study are important because they increase our understanding of violence against adolescent girls who were displaced from their homes and separated from their immediate families following a catastrophic natural disaster' and '(T)he results from this study suggest that there are many areas that organizations, foundations and governments can address in the future. Interventions and policy initiatives for adolescent girls should include education that increases their awareness of their vulnerability for gender-based violence as well as strategies for self-protection.'

Listen to this as a podcast


Sloand, E., Killion, C., Yarandi, H., Sharps, P., Lewis-O'connor, A., Hassan, M., Gary, F., Muller, C. N. and Campbell, D. (2017), Experiences of violence and abuse among internally displaced adolescent girls following a natural disaster. J Adv Nurs. doi:10.1111/jan.13316

Sunday, 23 April 2017

Caring for a dying child at home

Roger Watson, Editor-in-Chief

There can be few things that have more impact on a family than the death of a child. But the period leading up to death is also hard. Where parents may receive post-bereavement counselling, support is also needed when death is approaching as this study from Switzerland by Eskola et al (2017) titled: 'Maintaining family life balance while facing a child’s imminent death—A mixed methods study' and published in JAN explores.

The aim of the study was to: 'understand parents’ experiences and needs during a child’s end-of-life care at home and to identify systemic factors that influence its provision.' From a nationwide study in Switzrland between 2012-2015, 47 families were studied between 2011-2102 who had a dying child at home. Information from questionnaires and interviews was used.

The physical and emotional toll on some parents is captured in this quote from one father: 'I drove home in the evening, parked in front of the garage. . . Do you think I was able to get out of the car?! I remained seated three quarters of an hour, just sat there and slept. In fact, I was at home, but couldn’t manage to get out of the car. No energy, empty batteries.' Practical help was really appreciated as explained by one mother: 'This daily household crap—getting groceries, cooking, cleaning, paying the bills (. . .) It would have been so nice, if there had been somebody to take over all these tasks and we could have spent the time with our child.' The authors concluded: 'Paediatric end-of-life care at home is only feasible if parents make extraordinary efforts. If family-centred end-of-life home care is provided by a hospital-based paediatric palliative home care team, which includes paid housekeeping help and psychological support, parents needs could be better met.'

You can listen to this as a podcast


Eskola K, Bergstraesser E, Zimmerman K, Cignacco E (2017) Maintaining family life balance while facing a child’s imminent death—A mixed methods study Journal of Advanced Nursing DOI: 10.1111/jan.13304

Friday, 21 April 2017

Commentary on: Leading change: a concept analysis

Commentary on Nelson-Brantley H.V., and Ford D.J. (2017) Leading change: a concept analysis. Journal of Advanced Nursing 73(4), 834-846.

Dr Mark Hughes
University of Brighton, UK

As a management and organization studies academic with a strong interest in leading change, I read Nelson-Brantley and Ford’s (2017) recent paper with interest and I will certainly be referring to this informative paper in my future work. I share their desire for greater conceptual clarity around change leadership. Ford and Ford (2012) raised similar concerns, although not nursing specific, in their review of the leadership of organizational change literature published in peer-reviewed journals between 1990 and 2010.

As the authors rightly remind us, the focus of their concept analysis potentially has life or death consequences, so I do hope that their paper provokes much-needed debate, as the debate often appears to myself and others to be trapped in the past (see By et al, 2016). I want to fuel this debate through raising four challenges which could be directed at the paper and more generally at leading change theories and their implications for nursing practices.

1. Do aggregate success/failure rates inform or misinform nursing change practices?

A shift away from management towards leadership was prefaced by claims of change failure. In essence, change management failed, with an implication that change leadership was going to succeed. However, the evidence base for these highly publicized aggregate failure rates was non-existent (Hughes, 2011). Intuitively we appreciate that a success/failure rate for transforming a hospital will differ from the rate for improving nursing education given that they are completely different activities and that there will be considerable contextual variations even within nursing.

2. Are the prescriptions of Kotter really applicable to nursing change practices?

Professor John Kotter’s 1996 book features very prominently in the paper, potentially reflecting his contribution to leadership studies. Even assuming that Kotter’s business cases are applicable to healthcare settings, I have generic concerns about this model of leading change (Hughes, 2016). Over the past two decades, we have witnessed academic advances in understanding ethics, power and politics, processes, agency and discourses in relation to organizational change, which appear to be missing from Kotter’s account of leading change. It was disappointing that the conceptual analysis did not reveal ethics as one of the attributes for leading change or make any reference to ethics.

3. Do we need nurses to lead or manage change or both?

The call for nurses to lead change has been echoed in the UK. But as a patient of the UK National Health Service, rather than a practitioner, I fear we may underestimate management in delivering high-quality healthcare. As a patient more mundane aspects such as hospital cleanliness, available appointments, maintaining effective medical records and effective hospital communications with myself really do matter. My fear is that organizations have become seduced by notions of leading change at the expense of other crucial activities. The paper rightly touches upon dualities and paradox, but potentially misses an opportunity to encourage a dualities aware approach.
Effective change leadership means appreciating how dualistic forces can shape and enable change. By adopting a dualities aware perspective, leaders can come to terms with the intuitive desire to resolve contradiction by instead managing the complementarities within contradictory forces. (Sutherland and Smith, 2013: 220)
The implication is that rather than nurses leading or managing and dealing with change or continuity, they will typically be involved in managing and leading changes and continuities. In any effectively run hospital continuities may prove to be as important as changes and we may find managing those continuities is as important as leading changes.

4. Does associating leading with changing really inform nursing change practices?

The authors rightly tend to make associations between leading and changing, rather than asserting that leaders influence organizational change. Whilst institutional rhetoric of nurses leading change may be strong, I have reservations about the empirical reality of leaders influencing organizational change. Parry (2011:57) is cited in the concept analysis, but what I took away from his short review of leadership and organizational change was that ‘there are many more books and articles on practitioner or conceptual scholarship than on theoretical or empirical scholarship. Much of the practitioner work is case study-based, and anecdotal and not rigorous in its conduct.’ This concern could be levelled at some citations in the content analysis. I personally found Ford and Ford’s (2012:22) review of the leadership of organizational change literature persuasive:
There is simply too little empirical research that specifically addresses the leadership of change to warrant a prescription for what works…we find, the available research equivocal and incomplete regarding both what constitutes effective leadership and the impact of change leaders approaches, behaviors, and activities on change outcomes of any type.

I welcome the publication of this concept analysis in clarifying the concept of leading change and situating this analysis in the context of nursing and healthcare. I am personally still not convinced that we have the empirical evidence to satiate the institutional desires for leading change in healthcare or any other sector.

Dr Mark Hughes
Reader in Organizational Change
University of Brighton
Brighton Business School
Brighton, UK


By R.T., Hughes M & Ford, J. (2016) Change leadership: Oxymoron and myths. Journal of Change Management 16 (1), 8-17.

Ford, J.D. & Ford L.W. (2012) The leadership of change: A view from recent empirical evidence. In Research in Organization Change and Development (Pasmore W., Woodman, R and Shani, A. eds) 20: (1-36).

Hughes, M. (2011) Do 70 per cent of all organizational change initiatives really fail? Journal of Change Management 11(4), 451-464.

Hughes, M., (2016) Leading changes: Why transformation explanations fail. Leadership 12(4), 449-469.

Nelson-Brantley H.V. & Ford D.J. (2017) Leading change: a concept analysis. Journal of Advanced Nursing 73(4), 834–846. doi: 10.1111/jan.13223

Parry K.W. (2011) Leadership and Organization Theory. In The SAGE Handbook of Leadership (Bryman A., Collinson D., Grint K., Jackson, B. & Uhl-Bien, M. eds), SAGE Publications Ltd., London EC1Y 1SP, pp. 53.70.

Sutherland, F. & Smith, A.C.T. (2013) Leadership for the age of sustainability: A dualities approach to organizational change”. In Organizational Change, Leadership and Ethics: Leading Organizations Towards Sustainability (By R.T. & Burnes B. eds), Routledge, London, pp. 216-239.

Sunday, 16 April 2017

Improving outcomes in gastroesophageal cancer

Roger Watson, Editor-in-Chief*

What influences the time between developing gastroesophageal cancer and a doctor realising a patient has it? This was the subject of the a study titled: 'Which interval is most crucial to presentation and survival in gastroesophageal cancer: A systematic review' by Lee et al (2017) and published in JAN. The aim of the study was to: 'identify the most crucial interval to encourage earlier diagnosis in with gastroesophageal cancer and to identify potential factors effecting this interval' and the study used a systematic review method. Twelve articles published between 2000-2016 were analysed.

Three main themes were used to present the data: total delay; patient interval (ie time between symptoms and seeing a doctor); and treatment interval. In the words of the authors: 'This literature review identifies the patient interval as the most crucial factor for engaging in preventive measures to encourage earlier diagnosis. Most patients present at too late a stage for curation of GOC.' This supports UK government and cancer research charity calls for campaigns to increase earlier diagnosis by increasing awareness of symptoms in the general population. This should encouage people who have symptoms to see their doctor as early as possible, to receive trearment and survive longer. In conlusion, the authors say: 'The incidence of GOC is increasing across the globe, yet survival remains poor. However, there is a significant lack of focus on this cancer in the literature' and 'Potential sufferers of this cancer need to be encouraged to seek medical attention as the patient interval is the most crucial to survival. For this, community level interventions are required to raise awareness of the signs and symptoms of this cancer.'

*Declaration of interests: Roger Watson is a co-author of this article

Listen to this as a podcast


Lee A, Khulusi S, Watson R (2007) Which interval is most crucial to presentation and survival in gastroesophageal cancer: A systematic review Nursing Open DOI: 10.1111/jan.13308

Wednesday, 5 April 2017

What tells us that an older person is going to be malnourished in a nursing home?

Roger Watson, Editor-in-Chief

What indicates that an older person in a nursing home will develop malnutrition? That is the subject of a study by Bauer et al (2017) titled: 'Changes in nutritional status in nursing home residents and associated factors in nutritional status decline: a secondary data analysis' and published in JAN which aimed to: 'describe changes in the nutritional status of nursing home residents over a period of 1 year and identify factors associated with a decline in nutritional status'.

Using data from 157 older residents, several factors were related to the development of malnutrition. In the words of the authors: 'care dependency, length of stay, changes in body mass index and malnutrition risk at baseline were significantly associated with a decline in nutritional status.' However, risk of malnutrition at admission to a nursing home is 'the most important risk factor indicating a decline in nutritional status.' The authors conclude: 'Our findings indicate that it is critical for the topic of malnutrition to be emphasized in basic and advanced nursing educational programmes, to train nursing professionals to identify nursing home residents at risk effectively and early on. The identification of residents at risk should be performed during their admission to nursing homes and at regular time intervals using validated nutritional screening tools.'

You can listen to this as a podcast.


BAUER S., HALFENS R.J.G. & LOHRMANN C. (2017) Changes in nutritional status in nursing home residents and associated factors in nutritional status decline: a secondary data analysis. Journal of Advanced Nursing doi: 10.1111/jan.13297

How effective are physician substitutes?

Roger Watson, Editor-in-Chief

You may not be aware that in the NHS there are people with roles that are like doctors and nurses, but they are neither. Depending on your view these people can be either ‘super nurses’ or ‘sub-doctors’. But do they work?

A recent review of research compared these ‘substitute doctors’ roles with doctors in long-term care of older people. The results show they are better than doctors at improving health of patients, preventing secondary complications and completing care processes. They are equally as good as doctors at preventing deaths, providing medications and completing mandatory physical examinations. They are also cheaper. This is important as more older people spend their final years in long-term care, which is expensive and health service resources are scarce. 

There are two main substitute doctors roles are Nurse Practitioners and Physician Associates. They are different but have very similar roles in assisting or even substituting for doctors. Nurse Practitioners are Registered Nurses with advanced training in diagnosis and treatment. Physician Associates are science graduates with similar advanced training.

Like most of these advanced roles, Nurse Practitioners and Physician Assistants started in the USA. Nurse Practitioners began in the USA in the 1940s and they were trained in areas like midwifery and anaesthetics where they could work independently. Physician Associates started in the USA in the 1960s and their role was designed to assist doctors directly with examining patients and prescribing drugs. The two roles have spread across the world and Nurse Practitioners now exist in over fifty countries and Physician Associates exist in over ten countries.

Nurse Practitioners can perform many of the tasks of doctors and are generally well accepted in advanced roles by doctors. But less is known about the new Physician Associate roles and some doctors are worried. The role is recognised as one that can assist doctors but replacing doctors is another matter. The lack of professional registration, which helps to define a role, is one worry. It leads to a ‘fluid’ role which could be used to undermine the role of the doctor and take away training opportunities for junior doctors. Other than that, Physician Associates lack many of the skills required to work independently or unsupervised.

Nurse Practitioners – who have several titles – have existed for over twenty years in the UK and since this is not a ‘registerable’ profession, the exact numbers are not know but there are many hundreds working in the UK. Physician Associates have only existed here for about ten years and the government wants to increase their numbers. This is also not a registerable qualification and exact numbers are not known. But in 2014 there were around 200 in the UK with plans to increase that and more than double the number of training places from 100 to 225. The recent research showing that they can be successfully used to replace doctors is good news for the UK government and for UK universities.

The future for substitute doctors in the UK looks very good. Funding issues in the NHS probably make them a necessity. The evidence that they are effective in at least one important role and often better and cheaper that doctors will surely encourage more growth in training places and numbers in the NHS.

One issue remains for both Nurse Practitioners and Physician Associates and that is regulation. Being a Nurse Practitioner is what is known as a ‘recordable qualification’ and Nurse Practitioners can choose to do this with the Nursing and Midwifery Council. Of course, all Nurse Practitioners are Registered Nurses and must keep that status to work as Nurse Practitioners. For Physician Associates, there is the Faculty of Physician Associates at the Royal College of Physicians of London. Registering with them is only encouraged but not compulsory.

Proper registration and regulation of substitute physician roles will increase confidence in them and lead to wider acceptance. It is doubtful if people will turn up at doctors’ surgeries and say, ‘can I see the substitute physician?’. But soon it is more likely that this is who they will see.

You can listen to this as a podcast


Lovink MH, Persoon A, Koopmans RTCM, Van Vught AJAH, Schoonhoven L, Laurant MGH (2017) Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the aging population: a systematic literature review Journal of Advanced Nursing doi: 10.1111/jan.13299